Adult Services

Pathway transformation

Mark Lobban, Director of Commissioning Social Care, Health and Wellbeing, KCC Steven Phillips, Director, Newton Transformation (approach) Transformation (phasing)

**PHASE 1**

**Current Operating Model**

- Panel-focused care pathway
- Traditional system adjusted with independence-promoting services
- Time-consuming internal processes
- Time and task contracting relationships
- Large provider networks

**PHASE 2**

**PHASE 3**

**Delivering the Future Vision**

- Pathway working within the principles of care
- Integrated health and social care pathway, commissioning and provision
- Shaping the market through strategic engagement with key primary suppliers

**KCC**

- Organisational learning and development
- Fit for purpose: new BAU and on going transformational change

**Partners**

- Joint plans for integration based on evidence to facilitate a whole system understanding
- Alignment of transformational activity

**Markets**

- Working with providers to re-shape services models to meet future demand (shape & volumes) Transformation (phasing)

Delivering the Future Vision

- Pathway working within the principles of care
- Integrated health and social care pathway, commissioning and provision
- Shaping the market through strategic engagement with key primary suppliers

PHASE 3

PHASE 2

PHASE 1

£30M programme benefit

Current Operating Model

- Panel-focused care pathway
- Traditional system adjusted with independence-promoting services
- Time-consuming internal processes
- Time and task contracting relationships
- Large provider networks Transformation (phasing)

Delivering the Future Vision

- Pathway working within the principles of care
- Integrated health and social care pathway, commissioning and provision
- Shaping the market through strategic engagement with key primary suppliers

PHASE 2

- £16M+ programme benefit

PHASE 1

Current Operating Model

- Panel-focused care pathway
- Traditional system adjusted with independence-promoting services
- Time-consuming internal processes
- Time and task contracting relationships
- Large provider networks What the work looked at

What the work looked at – “Integrated flow”

Menu of Options – (including preventative) at key decision points that impact flow between partners

• Availability of options & decision consistency

What the work did not look at

This work did not look at the efficiency of delivery and pathways within the bounds of each separate organisation

• Based on Newton’s experience, we would typically realise a 5-15% improvement within each wave of transformation Findings

Can patients arriving at A&E be treated elsewhere? Could preventative support have been provided prior to attendance?

Mr F, 72:

- A gentleman with a known history of falls, has fallen for the 4th time and hurt his back – no preventative falls service has been provided to this point

Opportunities identified for improved pathways (decision making variability):

| Attendance | Admission | |------------|-----------| | 35% | 36% | Could the treatment provided in hospital be provided outside of the hospital for any patients?

Mrs V, 88:

- A lady ready to leave hospital after 9 days, delayed for a further 28 days (so far) whilst agreement is sought over the funding arrangements for her Nursing home. Acquired pneumonia in hospital

Opportunities identified for improved pathways (decision making variability):

- Attendance: 35%
- Admission: 36%
- Location: 20% Findings

When patients are discharged from the hospital, are the correct options available and selected? For SUs referred to social services, are the correct options available and routinely accessed?

Mr G, 81:

- IDT correctly planned to discharge patient into a community hospital bed with physical therapy – no capacity available. Then discharged to a basic short term bed by the Ward without therapy and Mr G eventually ended up in a residential home.

Opportunities identified for improved pathways (decision making variability):

| Attendance | Admission | Location | Discharge & Social Care | |------------|-----------|----------|-------------------------| | 35% | 36% | 20% | 44% | Findings

Is there opportunity to better coordinate services for citizens receiving both Community nursing and Social care provisions? Are packages of care appropriate in Community Nursing?

Community nurse (Band 6) quotes on work they are doing:

“The specialist diabetes nurses used to train residential staff to deliver insulin – that doesn’t happen anymore and we do the work”

“Of course [low level wounds] could be managed by Care workers”

Opportunities identified for improved pathways (decision making variability):

| Attendance | Admission | Location | Discharge & Social Care | DN not Req. | DN Skill Mix | |------------|-----------|----------|-------------------------|-------------|--------------| | 35% | 36% | 20% | 44% | 26% | 30% | Findings

How does LA commissioning compare to CCG commissioning?

CCQ quote: “That isn’t surprising as we spot purchase our beds”

Opportunities identified for improved pathways (decision making variability):

| Attendance | Admission | Location | Discharge & Social Care | DN not Req. | DN Skill Mix | CCG Commissioning | |------------|-----------|----------|-------------------------|-------------|--------------|-------------------| | 35% | 36% | 20% | 44% | 26% | 30% | 9% | Summary of where the system benefit arises

| Averages across areas | % case notes reviewed where a pathway improvement was identified | % of total financial savings identified attributable to this area | |------------------------------------------------------------|------------------------------------------------------------------|------------------------------------------------------------------| | ED attendances | 35% | 3% | | ED admissions | 36% | 42% | | Acute settings of care | 20% | 21% | | Acute discharge and local authority intake (together) | 44% | 17% | | Community nursing (overlap with LA provision and correct work/skill mix) | 56% | 12% | | CCG Commissioning | | 4% | | Total | 41% | 100% |

*Note for the financial modelling confidence weightings have been applied to the total opportunities identified based on practitioner input and Newton delivery experience. Additionally variable costs of alternative pathways have been modelled. These confidence factors vary between 10% and 75%.* Key Messages

• By focussing on the correct care pathway for citizens, significant patient / service user and financial benefit can be realised (~7-10% of budget assessed)

• Opportunities are driven by a variation in front line decision making

• The findings have identified two main areas where resources could be saved: – Avoidance of admissions to acute hospitals – Discharge planning, whilst maximising independent outcomes – Redeploying community nursing resource is a priority to realise the whole system opportunity Key Messages

• By focussing on the correct care pathway for citizens, significant patient / service user and financial benefit can be realised (~7-10% of budget assessed)

• **Opportunities are driven by a variation in front line decision making**

• The findings have identified two main areas where resources could be saved: – Avoidance of admissions to acute hospitals – Discharge planning, whilst maximising independent outcomes – Redeploying community nursing resource is a priority to realise the whole system opportunity Case Example – Acute Demand

Focus in the next few slides will be on discharge from the Hospital and impact on the Local Authority & partners. Case Example – Acute Demand

In 11% of cases residential was deemed appropriate. Case Example – Acute Demand

WHH

Referrals

Hospital Discharge Team

Home + Supporting Services

STB

LTB

Percentage of Service Users

- Incorrect Decision
- Pressure from family/friend
- Meet Housing Need
- Residential was appropriate
- Risk Adverse
- No clear goals Case Example – Acute Demand

Referrals: 3169

Hospital Discharge Team:

- 2912
- 212

Home + Supporting Services:

- 171

STB:

- 41

LTB:

- 45

86 LTB placements annually Case Example – Acute Demand

Referrals: 3169

Decision Point:

- 2912
- 212

Home + Supporting Services:

- 171

STB:

- 41

LTB:

- 45 Case Example – Acute Demand

| Service | GP | GP | Consult | Ward Nurse | Matron | Health DC | Social DC | |---------|----|----|---------|------------|--------|-----------|-----------| | Preventative | | | | | | | | | GP Services | | | | | | | | | Animal Care | | | | | | | | | Care Navigator | | | | | | | | | Carers Assessment | | | | | | | | | Families / Unpaid Carer | | | | | | | | | Postural Stability Clinic | | | | | | | | | Specialist Services | | | | | | | | | 0 Hour GP Services | | | | | | | | | Advocate Services | | | | | | | | | Community Geriatrician | | | | | | | | | Multidisciplinary Meeting | | | | | | | | | Equipment Support | | | | | | | | | House Clearance | | | | | | | | | Kent Enablement Service | | | | | | | | | Learning Disabilities Team | | | | | | | | | Mental Capacity Act | | | | | | | | | Occupational Therapist Clinics | | | | | | | | | Occupational Therapist Technician | | | | | | | | | Psychiatric Liaison | | | | | | | | | Re-ablement Beds | | | | | | | | | Telecare | | | | | | | | | Intervention | | | | | | | | | Ambulatory Care Pathways | | | | | | | | | Coastal Beds | | | | | | | | | Community Matrons | | | | | | | | | Community Pharmacy | | | | | | | | | Day Centre | | | | | | | | | Day Hospital | | | | | | | | | District Nurses | | | | | | | | | Domestic Violence Support | | | | | | | | | Early Supported Discharge | | | | | | | | | Fast Track | | | | | | | | | Health and Social Care Village Bed | | | | | | | | | Home Self Management | | | | | | | | | Home with ICT | | | | | | | | | Home with Care Package | | | | | | | | | Hospice | | | | | | | | | Integrated Care Centre | | | | | | | | | KMPT Mental Health Services | | | | | | | | | Outpatients Physio | | | | | | | | | Post ITU Rehab | | | | | | | | | Red Cross | | | | | | | | | Social Services | | | | | | | | | Specialist Nurses | | | | | | | | | Stepdown Bed | | | | | | | | | Community bed or at home | | | | | | | | | Continuing Health Care | | | | | | | | | KCC Care Home | | | | | | | | | NHS Care Home | | | | | | | | | Nursing Home | | | | | | | | | Private Care Home | | | | | | | | | Residential Care | | | | | | | | | Specialist Placement | | | | | | | | | Residential/ Nursing | | | | | | | |

Ward Staff Team Leader: “I don’t know half of what’s on there, the girls on the ward don’t stand a chance”

Matron: “We’re all talking different languages and patients are totally confused”

Pathway Team Manager: “Social Care can often only share previous care package details verbally and not in print, thus picking the most appropriate care is made far harder.”

It is not expected that every professional would know every service, but it is clear that the ward staff are not the best people to discuss post-acute services with the citizen and their family.

System needs to be designed so that the correct option is the easiest option.

www.local.gov.uk Case Example – Acute Demand

Vision: “A united team having open discussions to achieve the best outcomes for patients in a timely manner”

1. Identify and select the best outcome for each person
2. Understand and address the biggest issues preventing the most appropriate outcome
3. Escalate issues for Area- and County-wide action
4. Training, tools, processes and governance in place to support staff in the delivery of an effective service Any client with a chance of going to placement has a slip put up on the board.

- The progress of each case is tracked and each client on the board is discussed at the daily washup meeting.
- Meeting focuses on how to get each client home safely.
- Promotes peer review and ensures senior support as required.

Feedback from WHH team:

- “The new process provides more support for us”
- “It’s changed the way we think”
- “Makes us work more similarly and be more consistent in the way we work” Improving the decision making process and availability of alternative services (e.g. Hilton recovery service) has helped to dramatically reduce the number of inappropriate STB & LTB placements.

Integral to this improvement has been a change of culture, processes, practice and awareness of performance. This has now been rolled out across the 7 Acute hospitals in Kent with excellent results. Case Example – Acute Demand

“Everyone feels more supported in getting someone home.”

“The daily wash-up process provides us with a mechanism to ensure we are applying an evidence-based method of approaching cases and achieve the best outcome for service users”

59% Reduction in Long-Term Resi

54% Reduction in Short-Term Beds

LTB

STB

370 Extra People Going Back Home Each Year

Figures correct as of Apr ‘16 Each example of best practice observed during the review had followed a broadly consistent approach to implementing the change, highlighting the importance of the change model

1. Identifies, quantifies, and prioritises the opportunity
2. Set up for success
3. Top down alignment: Aligns the work with each organisation’s vision and incentives
4. Bottom up change: Co-designs solutions with front line users
5. Measures the performance
6. Tests the solutions in a live area, then redesigns and iterates as required
7. Standardises the new approach and only then rolls out at scale in implementation
8. Rationalises the subsequent menu of service and removes superseded options Have we been successful?

All Long Term Care Home Placements

Projection based on April 13-14

April 14 straight line projection

April 16-17 Projection

1523 Clients

707

400